Approximately half of all people with ADHD suffer from another condition. This is known as a comorbidity. Sometimes comorbidities are considered ‘secondary’ or triggered by ADHD. For example, a child could be particularly depressed because they are constantly being told off for being impulsive or not being able to focus on the task at hand. This will generally subside once the ADHD is diagnosed and treated. When the problems don’t resolve this is when a condition is considered comorbid or standalone, a diagnosis in itself. The condition is both chronic and pervasive. That means they were noticed early on in childhood and they occur in every life situation. These diagnoses will require their own treatment, in addition to ADHD treatment.
Comorbidities of ADHD in children generally fall into four categories:
Behavioural – Oppositional Defiance Disorder (ODD), Pathological Demand Avoidance (PDA), Conduct Disorder (CD)
Neurodevelopmental – Learning Disorders (LD) eg Dyslexia, Dyscalculia, ASD, Tourette’s Syndrome, Obsessive-Compulsive Disorder (OCD)
Mood Disorders – Depression, Bipolar Disorder
Other – Anxiety, Sleep Problems
Each of the below has a blog post which goes into far more detail about this individual disorder, so please click on the title if you wish to read on further.
Everyone has feelings of anxiety at some point in their life. For example, you may feel worried and anxious about sitting an exam or having a medical test or job interview.
Anxiety is considered a problem and termed General Anxiety Disorder (GAD) when you have chronic anxiety about common, everyday experiences and situations. It is a ‘long term’ condition that causes you to feel anxious about a wide range of situations and issues rather than one specific event. People with GAD feel anxious most days and often struggle to remember the last time they felt relaxed. As soon as one anxious thought is resolved, another may appear about a different issue’ (Taken from the NHS website).
ASD includes what used to be called Autistic Disorder, Asperger syndrome and Pervasive Developmental Disorder. All of these affect an individual’s social and emotional skills, plus non-verbal communication. It can also involve restrictive, repetitive, or ritualistic patterns of behaviour and sensory issues. Children with Autism generally do not fully grasp social situations. This will affect eye contact, social interactions, reading social cues and other people’s emotions. This can cause young children to not want to engage with others. Their ability to speak may be slower or not at all, which will also affect their socialisation with others.
Children with Autism are rigid with their routines. They need the ‘sameness’. This could be from food; needing the same colours, textures etc., to clothing; certain fabrics that may irritate; gestures; hand movements and directions to places. Children with ASD are often over-focused which enables them to remember detailed facts for a long time. No doubt this is where Dustin Hoffman’s ‘Rain Man’ character was derived from (great movie, although probably not entirely accurate).
Bipolar disorder is a mood disorder that causes extreme mood swings. It was previously known as manic depression. The highs, or manic episodes, can last for days or even weeks. During these times, people with bipolar disorder may have more energy than usual and feel like they can do anything. They may also act impulsively and make poor decisions, like spending too much money or engaging in risky activities. The lows, or depressive episodes, can last for weeks or even months. During these times, people with bipolar disorder may have trouble getting out of bed, and they may feel hopeless and worthless.
For children, the cycles between manic and depressive episodes can occur far more frequently, instead of over days, weeks or months, they can be all in one day.
Conduct disorder (CD) is a behavioural disorder characterised by aggressive and destructive behaviour. It is often diagnosed in childhood or adolescence and is thought to be the result of a combination of environmental and genetic factors. People with conduct disorder may have difficulty following rules, respecting authority figures, and interacting with others. *Blog post to follow shortly.
Depression is not just feeling sad or unhappy for a few days. It is a real and debilitating health condition that lasts for long periods of time and affects your day-to-day life. People cannot simply ‘snap out of it’ or just ‘pull themselves together’. A ‘lovely’ and very unhelpful bit of advice.
Depression can be inherited or can occur because of an event such as a death, frustration in life, divorce, pregnancy etc. Symptoms can appear both physically and mentally and affect someone’s behaviour.
Dyscalculia is a maths learning disorder. This involves difficulties with not only everyday numbers but also maths symbols (addition, subtraction, division, and multiplication), wording (one more than, one less than) and even visual-spatial information. Visual-spatial maths involves being able to process differences between a 6 and 9, W and M, following something in order, it can even cause tripping up the stairs due to not being able to calculate the heights.
Mild dyscalculia may allow basic maths knowledge to develop however, due to struggles with working memory, it becomes difficult to recite times tables for instance. Add this difficulty with memory to equations and algebra, and it’s easy to see how one could become completely overwhelmed.
Dysgraphia is a condition that affects a person’s ability to write correctly. The word dysgraphia comes from the Greek words dys meaning “impaired” and graphia meaning “writing by hand”. It includes not only difficulty with spelling, handwriting, and grammar but, also difficulty in forming letters, staying within the lines and writing legibly. Dysgraphia can make it hard for a person to express their thoughts in writing.
Dysgraphia is a learning disorder associated with both normal and above-average intelligence. Also worth noting is that many children with dysgraphia may not necessarily have problems with reading or speaking. It is estimated that between five and twenty percent of all children have some kind of deficit like dysgraphia. Dysgraphia is associated with dyslexia with spelling difficulties, but dysgraphia is a writing difficulty whereas dyslexia is concerned with reading difficulties.
Dyslexia is a learning disorder. It makes processing written and spoken language ridiculously hard. How it presents is very individual, just like ADHD! Some people have trouble pronouncing written words, even when they are their everyday words; some people have trouble decoding a word (phonemic awareness), or splitting it in the wrong way for example armchair could be armc-hair. Others have trouble remembering even simple words. Another challenge could be the rapid naming of letters, colours, pictures, and objects. However, someone could have extremely high verbal comprehension and amazing vocab yet struggle with their reading. Just as we see with ADHD it is very individual and therefore can be difficult to recognise.
Dyspraxia is a neurodevelopmental disorder. Also known as DCD, Developmental Coordination Disorder, a condition that affects fine and gross motor skills, coordination and movement. It is often referred to as a “motor learning disability.” This means that it can be difficult for people with dyspraxia to learn new motor skills, or to execute previously learned motor skills.
OCD – Obsessive Compulsive Disorder
OCD is a neurological disorder characterised by intrusive, unwanted thoughts, obsessions, and repetitive behaviours or compulsions. The thoughts and behaviours are typically unpleasant and can cause significant distress and impairment in daily functioning.
Approximately 2-3 % of all adults are affected by OCD, with 80% of these showing symptoms before the age of 18, in both males and females. According to the International OCD Foundation (IOCDF), 1 in 200 children suffer from it, with a quarter presenting by 14 years old. OCD occurs due to insufficient levels of the neurotransmitter, serotonin and over-activity in the brain.
The most common type is contamination OCD. This type involves unwanted and intrusive thoughts about germs, bacteria, or dirt. These thoughts can lead to compulsive behaviours such as excessive hand-washing, cleaning, or checking.
Other common types of OCD include hoarding OCD, where people have obsessive thoughts about acquiring and saving items; symmetry OCD, where people have obsessive thoughts about arranging things in a particular way; and order OCD, where people have obsessive thoughts about making sure everything is perfect.
People with OCD often perform these compulsions in an effort to relieve the anxiety caused by the obsessions. However, the compulsions only serve to temporarily relieve the anxiety and are not actually effective in solving the underlying problem. OCD can be a very debilitating condition that can interfere with all aspects of a person’s life.
ODD – Oppositional Defiance Disorder
Oppositional Defiant Disorder is exactly as the name sounds. The child will be extremely defiant and hostile, particularly towards a figure of authority. It is deemed a childhood behaviour disorder. For a diagnosis to occur, you must have seen this pattern of particularly hostile, vindictive and defiant behaviour for six months consecutively. Girls and boys can present differently with ODD as with ADHD. Boys are generally more physically aggressive whereas girls will be more likely to refuse to cooperate.
PDA – Pathological Demand Avoidance
PDA was first noted by a child psychologist, Prof Elizabeth Newson who saw that many children who came to her were, as she described, atypical autistic children. So, whilst the children had the autistic traits of social communication and interaction difficulties along with sensory issues, they also showed extreme avoidance of everyday demands and an anxiety-driven need to be in control. Many everyday demands are avoided simply because they are deemed as demands. The demand is seen as an expectation that increases anxiety and panic.
RSD – Rejection Sensitive Disorder
Rejection Sensitive Dysphoria is an intense emotional sensitivity whereby the individual believes they have been rejected by a person or criticised by someone important to them. Dysphoria comes from the Greek word meaning, ‘difficult to bear’. This does not mean they are weak, more that they find rejection very difficult to handle.
Often criticism can simply be perceived as such by the tone, which may or may not be there. However, it is very real to them, and they are not being ‘over-sensitive’ and should not be treated as such. People with RSD may be easily embarrassed; jealous; have low self-esteem and feel like failures; they may have problems with relationships; have heated emotional meltdowns when they feel like someone has criticised or rejected them; feel anxious in social settings and have intense mood swings. Even asking how something went can come across as interrogation rather than a genuine question by the tone, real or perceived.
According to the APA (American Psychiatric Society) the definition of a Sleep Disorder is “Sleep disorders (or sleep-wake disorders) involve problems with the quality, timing, and amount of sleep, which result in daytime distress and impairment in functioning. Sleep-wake disorders often occur along with medical conditions or other mental health conditions, such as depression, anxiety, or cognitive disorders. There are several different types of sleep-wake disorders, of which insomnia is the most common. ”
According to the NHS website, Tourette’s is “ a condition that causes a person to make involuntary sounds and movements called tics. It usually starts during childhood, but the tics and other symptoms usually improve after several years and sometimes go away completely. There’s no cure for Tourette’s syndrome, but treatment can help manage symptoms. *Again I will write a blog post about this soon.
As you can see, there are so many comorbidities that our children with ADHD could potentially suffer from. Some of their symptoms are so similar to those of ADHD that they can get missed. If you choose to medicate your child, most guidelines do recommend treating the ADHD diagnosis first, normally with stimulant medication. If this doesn’t seem to alleviate the major issues, it may mean you need to try another stimulant medication. My son was lucky the first time, my daughter tried about four or five before she found the one for her. If after diagnosis and treatment for ADHD, some of the problematic symptoms remain I would discuss these with your child’s paediatrician, CAMHs or whomever you have been dealing with. Keep notes as always.
I have started a private support group on Facebook for parents and carers who need support with their child with ADHD. It’s a friendly place to chat with others. Please do click this link ADHDinchildren to join. And for anyone on Instagram, I’m there too ADHD Mum.